{load_language_text section="contact_us"}
{load_language_text section="buttons" name="button"}

<div id="gm_callback_service_success" class="callback_service">

	<div id="gm_callback_service_error_message"></div>

	{if $CONTENT_TEXT}
		<div class="content_callback_service">{$CONTENT_TEXT}</div>
		<br />
	{/if}


	<div class="required_info">
		{$txt.text_required}
	</div>

	<form id="gm_callback_service_form" action="">
		<fieldset class="blocklabels_150">
			<div class="input">
				<label>{$NAME}</label>
				<input type="text" name="name" value="" class="input-text callback_service_fields" id="gm_callback_service_name" /> *
			</div>
			<div class="input">
				<label>{$EMAIL}</label>
				<input type="text" name="email" value="" class="input-text callback_service_fields" id="gm_callback_service_email" />
			</div>
			<div class="input">
				<label>{$TELEPHONE}</label>
				<input type="text" name="telephone" value="" class="input-text callback_service_fields" id="gm_callback_service_telephone" /> *
			</div>
			<div class="input">
				<label>{$TIME}</label>
				<input type="text" name="time" value="" class="input-text callback_service_fields" id="gm_callback_service_time" />
			</div>
			<div class="input">
				<label>{$MESSAGE}</label>
				<textarea name="message" class="input-textarea callback_service_fields">{$INPUT_TEXT_VALUE}</textarea>
			</div>
			{if $VALIDATION_ACTIVE == 'true'}
			<div class="input vvcode">
				<label>{$VALIDATION}</label>
				<div id="gm_callback_service_vvcode_image"><img src="{'gm_create_vvcodes.php'|xtc_href_link:'':'SSL':true}" alt="" title="" height="50" width="240" /></div>
				<input type="text" name="vvcode" value="" class="input-text callback_service_fields" id="gm_callback_service_vvcode" /> *
			</div>
			{/if}
		</fieldset>

		{if $GM_PRIVACY_LINK != '0'}
		<div id="gm_privacy">
			{$GM_PRIVACY_LINK}
			<br />
			<br />
		</div>
		{/if}

		<div class="send_button"><a href="{page_url}#" class="button_blue_big button_set_big" id="gm_callback_service_send"><span class="button-outer"><span class="button-inner">{$button.send}</span></span></a></div>

	</form>
</div>
<br />